Snake bite-Dr-Rizwan-ANMC- 2023-final.pptx

DR Rizwan Saeed
Prof Community Medicine
Azra Naheed Medical College
Superior University
Lahore
Pakistan

snake bite management is a public health importance as it has a very less notification rate. Snakes are available in all types of climates, geographical zones and environment. It has social, cultural and historic importance. They are present in deserts, grasslands, jungles, mountains, coastal areas, lakes, rivers, oceans and almost everywhere. Its health education and management related awareness is very important.

1. Snake bite by Prof. Dr. Rizwan Saeed (MBBS, DOMS, MPH, MME) DEPARTMENT OF COMMUNITY MEDICINE DIRECTOR STUDENT AFFAIRS Azra Naheed Medical College (ANMC) SUPERIOR UNIVERISTY LAHORE [email protected]

2. Scientific classification Kingdom: Animalia Phylum: Chordata Subphylum: Vertebrata Class: Reptilia Order: Squamata Suborder: Serpentes / ophedia ( venemous ) Linnaeus , 1758

3. Snakes are elongate legless carnivorous reptiles of the suborder Serpentes that can be distinguished from legless lizards by their lack of eyelids and external ears.

4. Snake bite is primarily a problem of the poorer rural populations farming activities . Poor access to health services fail to reach hospital in time . Hospital statistics on snakebites therefore underestimate the true burden. In addition to mortality , some snakebite victims survive with permanent physical squeal due to local tissue necrosis and, sometimes psychological squeal. Because most victims are young, the economic impact of snakebite can be considerable.

5. Living snakes are found on every continent except Antarctica. 15 families 456 genera over 2,900 species . range in size from the tiny, 10 cm long thread snake to pythons and anacondas of up to 7.6  metres (25 ft) in length. Most species are non-venomous and those that have venom use it primarily to kill and subdue prey rather than self-defense. Some possess venom potent enough to cause painful injury or death to humans.

6. evolution 150 million-year-old specimens, readily identifiable as snakes, yet with lizard-like skeletal structures, have been uncovered in South America and Africa . There is consensus, on the basis of comparative anatomy , that snakes descended from lizards . Fossil evidence suggests that snakes may have evolved from burrowing lizards

7. VENOM The term poisonous snake is mostly incorrect—poison is inhaled or ingested whereas venom is injected Vipera berus , one fang in glove with a small venom stain, the other still in place Cobras, vipers, and closely related species use venom to immobilize or kill their prey. The venom is modified saliva , delivered through fangs DRY BITE The standard way of estimating the strength of any toxin is to inject a thin solution into standard size laboratory mice, to establish a LD50 dose , i.e. a dose that on average will kill half of the mice in 24 hours

8. Snake venoms complex mixtures of proteins and are stored in poison glands at the back of the head . These proteins can potentially be a mix of neurotoxins ( which attack the nervous system ) Hemotoxins (which attack the circulatory system ) Cytotoxins (which damages the cells) Myotoxins (which damages the Muscles cells) Bungarotoxins NEUROTOXIN (PROTEINS-KRAITS) and many other toxins that affect the body in different ways .

9. Snake Venom Almost all snake venom contains hyaluronidase , an enzyme that ensures rapid diffusion of the venom F A N G S

10. SNAKE BITE The most common symptoms of all snakebites are panic, fear and emotional instability, which may cause symptoms such as nausea and vomiting , diarrhea , vertigo , fainting , tachycardia , and cold, clammy skin.  Television, literature, and folklore are in part responsible for the hype surrounding snakebites, and a victim may have unwarranted thoughts of imminent death.

11. SEQULAE OF SNAKE BITE NO EFFECT PSYCHOGENIC EFFECT ENVENOMATION NEUROTOXIC SEQULAE MYOTOXIC EFFECTS SEQULAE OF WRONG INDIGENOUS PROCEDURES OTHER COMPLICATIONS COMPLICATIONS OF TOURNIQUET COMPLICATIONS OF INCISIONS WOUND SEPSIS POSSIBLE HAZARDS OF ANTIVENIN LOCAL EFFECT HAEMOTOXIC

12. i ) cytotoxins  causing local swelling and tissue damage, ii) haemorrhagins  which disturb the integrity of blood vessels, iii) compounds  which lead to incoagulable blood, iv) neurotoxins  causing in neurotoxicity v) myotoxins  which cause muscle breakdown

13. Dry snakebites , Those inflicted by a non-venomous species, are still able to cause severe injury to the victim.  a snakebite which is not treated properly may become infected the bite may cause anaphylaxis in certain people, and the snake's saliva and fangs may harbor many dangerous microbial contaminants, including Clostridium tetani .  If neglected, an infection may spread and potentially kill the victim.

14. INOCULATION / INJECTION BY SNAKE ENTERS SURROUNDING TISSUE CAPILLARRY ABSORPTION LYMPHATIC BLOOD VESSELS TARGET ORGANS SYSTEMIC EFFECT RECOVERY DEATH AUTO-PHARMACOLOGICAL MANIFESTATION DIRECT VENOM ACTION

15. Most snakebites, whether by a venomous snake or not, will have some type of local effect. In over 90% of cases there is minor pain and redness , but this varies depending on the site. Bites by vipers and some cobras may be extremely painful, with the local tissue sometimes becoming tender and severely swollen within 5 minutes. Other common initial symptoms of pit viper bites include lethargy, weakness, nausea, and vomiting . Symptoms may become more life-threatening over time, developing into hypotension , tachypnea , severe tachycardia, altered sensorium , and respiratory failure

16. Australian Elapids , Viper coagulopathy Cobras, Kraits, Mambas, Sea snakes Neurotoxicity Victim not treated May die of Respiratory failure

17. necrosis of muscle tissue Muscle tissue will begin to die throughout the body, a condition known as rhabdomyolysis . Dead muscle cells may even clog the kidney which filters out proteins. This, coupled with hypotension , can lead to acute renal failure , and, if left untreated, eventually death

18. Interestingly, bites caused by the rattlesnake , coral snake , and the speckled rattlesnake reportedly cause little or no pain despite being serious injuries. Victims may also describe a "rubbery," "minty ," or "metallic " taste if bitten by certain species of rattlesnake. Spitting cobras and rinkhalses can spit venom in their victims' eyes. This results in immediate pain, ophthalmoparesis , and sometimes blindness

19. Snakes do not ordinarily prey on humans and most will not attack humans unless the snake is startled or injured, preferring instead to avoid contact. non-venomous snakes are usually not a threat to humans. venomous snakes present far greater hazard to humans Snakes are most likely to bite when they feel threatened , are startled, provoked, or have no means of escape when cornered

20. DEATH WITH SNAKE BITE Documented deaths resulting from snake bites are uncommon. Non-fatal bites from venomous snakes may result in the need for amputation of a limb or part thereof. Of the roughly 725 species of venomous snakes worldwide, only 250 are able to kill a human with one bite.

21. TREATMENT The treatment for a snakebite is as variable as the bite itself. The most common and effective method is through anti-venom , a serum made from the venom of the snake. Some anti-venom is species specific ( monovalent ) while some is made for use with multiple species in mind (polyvalent). In the United States for example, all species of venomous snakes are pit vipers , with the exception of the coral snake . To produce antivenin, a mixture of the venoms of the different species of rattlesnakes , copperheads, and cottonmouths is injected into the body of a horse in ever-increasing dosages until the horse is immunized. Blood is then extracted from the immunized horse and freeze-dried. It is reconstituted with sterile water and becomes antivenin. For this reason, people who are allergic to horses cannot be treated using antivenin . Antivenin for the more dangerous species (such as mambas , taipans , and cobras ) is made in a similar manner in India, South Africa, and Australia with the exception being that those antivenins are species-specific.

22. Keep the victim calm , restrict movement. •  The limb , which has been affected by the bite, should be immobilized with splint and be kept below the level of the heart . A compression bandage (not tight) should cover the entire limb with the splint. •  Assure the victim and do not let him panic . When under panic, it will enhance heart rate and would circulate the venom faster in the body. •  Remove any rings or constricting items, jewelry ; the affected area may swell. •  A snakebite victim is under tremendous psychological stress. It is necessary to keep the patient warm . However, no alcohol/hot beverages should be given. The patient should not be allowed to exert himself in any manner.

23. DO NOT COVER THE BITE AREA AND PUNCTURE MARKS . The wound should be gently cleaned with antiseptic. •  Try to aspirate the venom out of the puncture marks with standard suction devices. It has been identified that a suction more than 270 mmHg can initiate the flow from the puncture marks. Suction instruments often are included in commercial snakebite kits.  But, the suction should be applied within 5 minutes of the bite. The only remedy for venomous snakebite is the anti-venom serum , which is available at most government hospitals and public health centers. Some private nursing homes have also started stocking it and treat snakebite cases.

24. Snake trapping The tribals of " Irulas " from Andhra Pradesh and Tamil Nadu in India have been hunter-gatherers in the hot dry plains forests and have practiced this art for generations. They have a vast knowledge of snakes in the field. Irulas generally catch the snakes with the help of a simple stick SNAKE SKIN SNAKE VENOM

25. PETS : BALL PYTHON & CORN SNAKE

26. SYMBOLISM Medusa by 16th Century Italian artist Caravaggio Rod of Asclepius, in which the snakes, through ecdysis , symbolize healing.

27. HISTORY / RELEGION In Egyptian history , the snake occupies a primary role with the Nile cobra adorning the crown of the pharaoh in ancient times. It was worshipped as one of the gods and was also used for sinister purposes: murder of an adversary and ritual suicide ( Cleopatra ). The snake is one of the 12 celestial animals of Chinese Zodiac , in the Chinese calendar . The cobra is seen on the neck of Shiva and Vishnu is depicted often as sleeping on a seven-headed snake or within the coils of a serpent

28. Snakebites Poisonous snakes in the U.S. Rattlesnake Copperhead Water moccasin Coral snake

29. Pit Vipers Rattlesnake Copperhead Water moccasin Characteristics: Flat heads that are wider than their necks (triangular) “Cat eyes” (elliptical) Heat sensitive “pit” between the eye and nostril on each side of the head

30. Pit Viper Bites: Signs and Symptoms Severe burning/ fang marks Swelling (occurs in 5 minutes and can involve entire extremity) Mark extent of swelling on body 6-10 hours later: potential discoloration and blood filled blisters

31. Coral Snake Bites Most venomous, but rarely bites Red, yellow and black band Every other band is yellow Red on yellow, kill a fellow . Red on black, venom lack.

32. Cobra Viper 1 Venom is neurotixic Venom is vasculotoxic 2 Injects almost all venom Injects little venom 3 Local symptoms are mild Intense local pain and cellulitis 4 Effects are mainly on CNS Effects are mainly on CVS 5 Lay eggs Give birth to living ones 6 Pupils are circular Pupils are elliptical 7 head and neck of same width Head usually with small scales & neck narrow

33. Snake Bites: What To Do #1 (controversial but generally recommended) Pit Viper Get away from snake / may re-strike Can strike ½ the length of their body A decapitated head can react for 20 more minutes Have victim lie down and stay calm Do not move victim unless absolutely necessary Keep bitten area immobile and below the level of the heart Call 1122 Wash area with soap and water

34. Snake Bites: What To Do #2 If more than 1 hour from medical facility, use “extractor” within 3 minutes and left on for 30 minutes (pit vipers only) (up to 30% of venom may be removed) Seek medical attention immediately Anti-venom available only at hospitals Same anti-venom used no matter type of snake Must be given within 4 hours of the bite

35. Icing is generally not helpful “Cut and suck method” (Increases risk of infection) No constriction bands (Gangrene) Old style snake bite kit that should NOT be used NOLT TO DO

36. Application of a tourniquet to the bitten limb is generally not recommended. There is no convincing evidence that it is an effective first aid tool as ordinarily applied . Uninformed tourniquet use is dangerous, since reducing or cutting off circulation can lead to gangrene , which can be fatal

37. No application of potassium permanganate Use of electroshock therapy . Although still advocated by some, animal testing has shown this treatment to be useless and potentially dangerous

38. Until the advent of antivenom , bites from some species of snake were almost universally fatal. Despite huge advances in emergency therapy, antivenom is often still the only effective treatment for envenomation . The first antivenom was developed in 1895 by French physician Albert Calmette for the treatment of Indian cobra bites Immunization against snake venom ?

39. antivenom Anti-Snake venom serum is a sterile preparation containing purified and concentrated immunoglobulins obtained from the serum of healthy horses immunized against the venoms of the following four common poisonous snakes of Pakistan namely: Cobra Krait Russell’s viper Saw scaled viper

40. Supportive and symptomatic measures Bed rest Warmth Analgesics and sedatives (codeine, meperedine avoid morphine d ˚ risk of respiratory failure) Shock (fluid electrolyte balance, blood transfusion) Ventilation support (O 2 in hypoxia- neurotoxin, tracheotomy) Antibiotics Tetanus- gas gangrene prophylaxis Heparin (in DIC evidence in haemolysis , Hb drop) Steroids (deals allergic manifestations of antivenin)

41. Coral Snake Bites: What To Do Coral Snake Use same methods except: Do not use “extractor” Apply mild pressure over the bite site and wrap entire limb with an ace bandage No ice is necessary

42. Non-Poisonous Bites Horse shoe shaped tooth marks May be painful but no systemic reactions What To Do? Minor wound treatment If in doubt, go to hospital or call Dr.

43. PREVENTION Sign at Sylvan Rodriguez Park in Houston, Texas warning of the presence of snakes

44. Snake Bite Prevention Use caution around wood piles, rock crevices etc. Watch where you step Do not reach into holes or hidden ledges Wear boots ( 50%BITES BELOW KNEE ), long pants, long sleeved shirts Don’t sit or step over logs without checking it out Use a walking stick, Torches When camping, keep tent zipped at all times (float trip ) ( child sat on snake) Take a friend along Stay out of tall grass Leave snakes alone Public education (first aid management)

45. Prevention (cont..) 1) Any unknown snake is potentially dangerous ; do not play, avoid any contact with any snake including those of small size, baby, lethargic, dead. A cut off head can keep poisonous activities for several minutes. Make yourself familiar with the description of poisonous snakes in the place where you live. 2) Attention!!! Use torchlight at night – all local poisonous snakes are active in the evening and at night. Pay more attention in the forest, close to bushes, tall plants, etc. 3) Snakes usually don't bite you without alarm : - Cobra – lifts vertically front part of the body (1/3), opens hood, makes hiss, rushes to the aim. - Vipers - make a spiral from a tail, bend like zigzag front part of the body, and make a strong hiss. 4) If you meet a snake, go back slowly , don't do sudden movements, do not turn your back to the snake, do not run, and give the possibility for a snake to go away

46. Reassurance and immobilization of the affected limb with prompt transfer to a medical facility are the cornerstones of the immediate care of snakebite. Pressure immobilization is used for some elapid species. The mainstay of treatment of snakebite is the infusion of an appropriate antivenom . Snake venoms are diverse, and therefore the efficacy of antivenoms is geographically and biologically restricted, meaning that a large number of antivenoms have been developed for use in different settings Antivenoms are manufactured by immunizing horse or sheep with venom from a particular species and then processing the serum from the animal. Both monospecific and polyspecific antivenoms are available; monospecific antivenoms are produced using the venom of a single species, whereas polyspecific antivenoms are produced against the venoms of several species that are prevalent in a geographic region. In the rural tropics, victims are often bitten in an agricultural field or jungle, and in many instances the biting species is not identified. In such situations, treatment with polyspecific rather than monospecific antivenoms may be more appropriate

47. Snakes: Additional Information Poor vision, especially when shedding Prime time for crawling snakes in this area: August Baby snakes have stronger venom Snakes just out of hibernation have stronger venom Many organizations, including the American Medical Association and American Red Cross , recommend washing the bite with soap and water . However, do not attempt to clean the area with any type of chemical

48. To train farmers, students and traditional healers in first-aid for snakebite To discourage dependency on traditional healers To familiarize people with venomous snake To know the impact of snakebite first-aid education. We need to :

49. Pressure immobilization

50. Estimates vary from 1.2 to 5.5 million snakebites, 421,000 to 2.5 million envenomings , and 20,000 to 125,000 deaths. Since reporting is not mandatory in much of the world, the data on the frequency of snakebites is not precise.  Many people who survive bites have permanent tissue damage caused by venom, leading to disability.  Most snake envenomings and fatalities occur in  South Asia ,  Southeast Asia , and  sub-Saharan Africa , with  India  reporting the most snakebite deaths of any country. Most snakebites are caused by non-venomous snakes. Of the roughly 3,000 known species of snake found worldwide, only 15% are considered dangerous to humans. Snakes are found on every continent except  Antarctica .  Worldwide, snakebites occur most frequently in the summer season when snakes are active and humans are outdoors. Agricultural and tropical regions report more snakebites than anywhere else. EPIDEMIOLOGY

51. COBRA MAP PAKISTAN

52. DEATH / 100,000 DUE TO SNAKE BITE PAKISTAN = 1.90  1.1 INDIA 5.40 BURMA 15.40 TRINIDAD & TOBAGO = 2.49 (2007)

53. A woman has lost her life due to venomous snakebite in Nowshera , district of KPK. More than one hundred people have also suffered a snakebite in a disastrous flood across the country. 35 in DGK, 3 KhairPur etc. (02-09-2022)

54. Most snakebites are caused by non-venomous snakes. Of the roughly 3,000 known species of snake found worldwide, only 15 % are considered dangerous to humans. Most fastest and dangerous venomous snake is BLACK MAMBA in one strike it bites about 20 times and for a human it takes nearly 30 min to die. Since reporting is not mandatory in many regions of the world, snakebites often go unreported .

55.   King Cobras could grow at the maximum length of 18.8 ft (av. 9.8 – 13 ft) and weighs around 13 kg. King Cobras are commonly found in India, China, and Indonesia. The venom of Cobra species could easily kill more than hundred people at a time and also a giant elephant in minutes. Venom quantity 200 – 500 mg. Very vulnerable for humans, unpredictable & can sneak. Most intelligent snake.They can sense (chemical information) from 100 m. Snake predator. Black Mambas is considered the most dangerous snakes in the world. Black Mambas are commonly found in the Eastern and Southern parts of Africa. Black Mamba does not appear in the human presence or in the living area. Black Mamba would attack people when they are threatened. They are diurnal. This snake is the longest venomous snake in the Africa Continent. Black Mambas are scarier as well as dangerous and the 14ft (av. 8-10 ft). Long Black Mamba could slither at a great speed up to 12.5 miles per hour.  Venom quantity 50 – 120 mg. They can sense humans from 40 m. Either chase or run away.

56. CONCLUSION snakebite mainly affects the rural men of developing countries. Availability of anti-venom at primary healthcare centre's and rapid transportation facilities may change the morbidity associated with snakebites. Early administration of the polyvalent anti-venom has reduced morbidity and mortality but is associated with anaphylaxis in small group of patients. There is need to educate the rural population about the hazards and treatment of snake bites. randomized controlled trials are needed to investigate the issue of rationale of anti-venom treatment.

57. REMEMBER   •  As a common man, one should know how to administer proper first-aid to a snakebite victim, without losing precious time. •  Never try to assess whether it was venomous snakebite or not. As a layman one should treat every snakebite as venomous snakebite , as some snake venom (like that of common krait) does not show immediate effect even in the case of a serious bite, it is wise to rush to a hospital. •  Even if in doubt about whether it is a snakebite or not, do the first-aid and rush the victim to the nearest hospital. •  Educate your children that putting one's hand into any kind of burrow could be dangerous.  

58. •  Never get into a dark bathroom ; first switch on a light and then see around you before you enter. •  Not all bites from venomous snakes lead to death; many venomous snakes (and as many as 85% of snakes are non venomous) deliver only a dry bite to humans. Even in the case of a full bite, with appropriate first-aid, care and treatment a snake bite victim can fully recover . Very few venomous snakebites are fatal . Just as every mosquito bite does not cause malaria, so every snakebite does not cause death. •  No attempt should be made to kill the snake to carry it along to the hospital. It would result in delaying the arrival of the patient to the hospital and is potentially dangerous for the person who will attempt killing the snake . Qualified doctor can diagnose observing the patient for clinical symptoms and pathological tests. Viperine bites cause consumption coagulopathy and the best method of diagnosing this is the 20 Minute Whole Blood Clotting Test (20WBCT).

59. All snakes are not venomous – so every snakebite is not going to result in death – it would save people from quacks. And reduce the amount of panic and chaos. Even a venomous bite is not always fatal – because the severity of snakebite depends on many factors like the size of the snake, whether the bite could be completed, whether it was a dry bite or not, the age, physique and affected limb of the victim. Cobra injects 50% venom usually in a single bite. First Aid would enable a person to buy more time to reach medical aid on time. The only cure which is available is anti-venom serum injection and not quacks . First Aid - if not done properly could cause more harm than benefit .

60. In Pakistan the criteria for ASV administration Incoagulable blood determined by the 20WBCT 2. Visible neurological signs such as ptosis or ophthalmoplegia or other evidence of descending paralysis. 3. Clear evidence of current systemic bleeding e.g. haemoptysis . Pre medications with either hydrocortisone and antihistamine or subcutaneous adrenaline are commonly used methods by doctors in Pakistan to prevent adverse reactions to ASV.

61. Equipment tray 1. Anti snake venom . 2. Test tubes , new, clean, dry and glass for 20WBCT. 24 vials are required for all patients. 3 . Neostigmine and atropine . 20 ampoules of 0.5mg neostigmine should be obtained for the average number of victims who present visible neurological signs per month. Three will be used in the initial neostigmine test and others will be required for continuing treatment. The actual number held will vary by location as some districts such as Mirpurkhas have higher levels of neurotoxic envenomation than others. 4. Adverse reaction drugs. Adrenaline (1:1000) is priority and 10 vials of 1mg should be kept on the snakebite tray. 5 vials of 100mg hydrocortisone and 5 vials of 22.5mg Phenimarine maleate should be available for longer term protection and support. 5. Pain medication . Paracetamol tablets 500mg are the preferred pain medication, and not aspirin. 6. Resuscitation bag . 7. Airway support Kit . If such a tray is made available in each hospital, including Basic Health Units (BHU) and Rural Health Centers (RHC), snakebite mortality will be dramatically reduced.

62. #1 Inland Taipen (LD50=0.01 mg 44-110 mg/bite)

63. #3: Forest Cobra (LD50=0.22 mg 570-1100 mg/bite)

64. #4: Dubois’s Sea Snake (LD50=0.04 mg 1-10 mg/bite)

65. #6: Black Mamba (LD50= 0.3 mg 100-400 mg/bite)

66. #7: Russell’s Viper Russell’s vipers are so venomous that they have a mortality rate of around 2.6% in India. (LD50= 0.16 mg 130-250 mg/bite)

67. #8: Boomslang Despite belonging to the Colubridae family, the boomslang is extremely venomous, capable of opening its jaw 170 degrees in order to bite. Haematotoxic (LD50=0.1 mg 1-8 mg/bite)

68. #1 - Taipans (genus Oxyuranus ) #2 - Krait ( Bungarus coeruleus ) TOP 5 Venemous SNAKES #3 - Philippine Cobra ( Naja naja philippinensis ) #4 - King cobra ( Ophiophagus hannah ) #5 - Russell's viper ( Daboia russelli )

69. World's Deadliest Snakes King Cobra ( Ophiophagus hannah ) ... Black Mamba ( Dendroaspis polylepis ) ... Boomslang ( Dispholidus typus ) ... Saw-Scaled Viper (genus: Echis , several species) ... Inland Taipan ( Oxyuranus microlepidotus ) ... Gabon Viper ( Bitis gabonica ) ... Eastern Diamondback ( Crotalus adamanteus )

70. https://us06web.zoom.us/j/84415363526?pwd=SDlnVXdOVHVheGxnSEl2SW5QaWc4UT09 https://a-z-animals.com/blog/the-top-10-most-venomous-snakes-in-the-world/

71. THANK YOU